[Show abstract][Hide abstract] ABSTRACT: Purpose:
The American College of Rheumatology (ACR) 2010 preliminary fibromyalgia diagnostic criteria require symptom ascertainment by physicians. The 2011 "survey" or "research" modified ACR criteria use only patient self-report. We compared physician based (MD) (2010) and patient based (PT) (2011) criteria and criteria components to determine the degree of agreement between criteria methodology.
We studied prospectively collected, previously unreported rheumatology practice data from 514 patients and 30 physicians in the ACR 2010 study. We evaluated the widespread pain index (WPI), polysymptomatic distress scale (PSD) scale, tender point count (TPC) and fibromyalgia diagnosis using 2010 and 2011 rules. Bland-Altman 95% limits of agreement (LOA), kappa statistic, Lin's concordance coefficient and area under the receiver operating curve (ROC) were used to measure agreement and discrimination.
MD and PT diagnostic agreement was substantial (83.4%, kappa = 0.67). PSD scores differed slightly: 12.3 for MD and 12.8 by PT (p=0.213). LOA for PSD were -8.5 and 7.7, with bias of -0.42. The TPC was strongly associated with the MD (r=0.779) and PT PSD scales (r=0.702).
There was good agreement in MD and PT fibromyalgia diagnosis and other measures among rheumatology patients. Low bias scores indicate consistent results for physician and patient measures, but large values for LOA indicate many widely discordant pairs. There is acceptable agreement in diagnosis and PSD for research, but insufficient agreement for clinical decisions and diagnosis. We suggest adjudication of symptom data by patients and physicians, as recommended by the 2010 ACR criteria. This article is protected by copyright. All rights reserved.
[Show abstract][Hide abstract] ABSTRACT: To summarize the development of evidence-based guidelines for the clinical care of persons with fibromyalgia (FM), taking into account advances in understanding of the pathogenesis of FM, new diagnostic criteria, and new treatment options.
Recommendations for diagnosis, treatment, and patient followup were drafted according to the classification system of the Oxford Centre for Evidence-Based Medicine, and following review were endorsed by the Canadian Rheumatology Association and the Canadian Pain Society.
FM is a polysymptomatic syndrome presenting a spectrum of severity, with a pivotal symptom of body pain. FM is a positive clinical diagnosis, not a diagnosis of exclusion, and not requiring specialist confirmation. There are no confirmatory laboratory tests, although some investigation may be indicated to exclude other conditions. Ideal care is in the primary care setting, incorporating nonpharmacologic and pharmacologic strategies in a multimodal approach with active patient participation. The treatment objective should be reduction of symptoms, but also improved function using a patient-tailored treatment approach that is symptom-based. Self-management strategies combining good lifestyle habits and fostering a strong locus of control are imperative. Medications afford only modest relief, with doses often lower than suggested, and drug combinations used according to clinical judgment. There is a need for continued reassessment of the risk-benefit ratio for any drug treatment. Outcome should be aimed toward functioning within a normal life pattern and any culture of disablement should be discouraged.
These guidelines should provide the health community with reassurance for the global care of patients with FM with the aim of improving patient outcome by reducing symptoms and maintaining function.
The Journal of Rheumatology 07/2013; 40(8). DOI:10.3899/jrheum.130127 · 3.19 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: <⁄span> Recent neurophysiological evidence attests to the validity of fibromyalgia (FM), a chronic pain condition that affects >2% of the population.
<⁄span> To present the evidence-based guidelines for the diagnosis, management and patient trajectory of individuals with FM.
<⁄span> A needs assessment following consultation with diverse health care professionals identified questions pertinent to various aspects of FM. A literature search identified the evidence available to address these questions; evidence was graded according to the standards of the Oxford Centre for Evidence-Based Medicine. Drafted recommendations were appraised by an advisory panel to reflect meaningful clinical practice.
<⁄span> The present recommendations incorporate the new clinical concepts of FM as a clinical construct without any defining physical abnormality or biological marker, characterized by fluctuating, diffuse body pain and the frequent symptoms of sleep disturbance, fatigue, mood and cognitive changes. In the absence of a defining cause or cure, treatment objectives should be patient-tailored and symptom-based, aimed at reducing global complaints and enhancing function. Healthy lifestyle practices with active patient participation in health care forms the cornerstone of care. Multimodal management may include nonpharmacological and pharmacological strategies, although it must be acknowledged that pharmacological treatments provide only modest benefit. Maintenance of function and retention in the workforce is encouraged.
<⁄span> The new Canadian guidelines for the treatment of FM should provide health professionals with confidence in the complete care of these patients and improve clinical outcomes.
[Show abstract][Hide abstract] ABSTRACT: To provide an update on advances in pain research and practical guidelines for pain management in the rheumatic diseases.
A selected literature review and authors' conference consensus.
There is emerging evidence that augmented pain regulation, as found in fibromyalgia, is important in rheumatoid arthritis and osteoarthritis. These findings are applicable to optimal management paradigms in the rheumatic diseases.
Fibromyalgia and other forms of chronic widespread pain have taught us important lessons about pain epidemiology and pain pathways.
Seminars in arthritis and rheumatism 06/2011; 41(3):319-34. DOI:10.1016/j.semarthrit.2011.04.005 · 3.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To develop a fibromyalgia (FM) survey questionnaire for epidemiologic and clinical studies using a modification of the 2010 American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia (ACR 2010). We also created a new FM symptom scale to further characterize FM severity.
The ACR 2010 consists of 2 scales, the Widespread Pain Index (WPI) and the Symptom Severity (SS) scale. We modified these ACR 2010 criteria by eliminating the physician's estimate of the extent of somatic symptoms and substituting the sum of 3 specific self-reported symptoms. We also created a 0-31 FM Symptom scale (FS) by adding the WPI to the modified SS scale. We administered the questionnaire to 729 patients previously diagnosed with FM, 845 with osteoarthritis (OA) or with other noninflammatory rheumatic conditions, 439 with systemic lupus erythematosus (SLE), and 5210 with rheumatoid arthritis (RA).
The modified ACR 2010 criteria were satisfied by 60% with a prior diagnosis of FM, 21.1% with RA, 16.8% with OA, and 36.7% with SLE. The criteria properly identified diagnostic groups based on FM severity variables. An FS score ≥ 13 best separated criteria+ and criteria- patients, classifying 93.0% correctly, with a sensitivity of 96.6% and a specificity of 91.8% in the study population.
A modification to the ACR 2010 criteria will allow their use in epidemiologic and clinical studies without the requirement for an examiner. The criteria are simple to use and administer, but they are not to be used for self-diagnosis. The FS may have wide utility beyond the bounds of FM, including substitution for widespread pain in epidemiological studies.
The Journal of Rheumatology 02/2011; 38(6):1113-22. DOI:10.3899/jrheum.100594 · 3.19 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Previous research has suggested that tai chi offers a therapeutic benefit in patients with fibromyalgia.
We conducted a single-blind, randomized trial of classic Yang-style tai chi as compared with a control intervention consisting of wellness education and stretching for the treatment of fibromyalgia (defined by American College of Rheumatology 1990 criteria). Sessions lasted 60 minutes each and took place twice a week for 12 weeks for each of the study groups. The primary end point was a change in the Fibromyalgia Impact Questionnaire (FIQ) score (ranging from 0 to 100, with higher scores indicating more severe symptoms) at the end of 12 weeks. Secondary end points included summary scores on the physical and mental components of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). All assessments were repeated at 24 weeks to test the durability of the response.
Of the 66 randomly assigned patients, the 33 in the tai chi group had clinically important improvements in the FIQ total score and quality of life. Mean (+/-SD) baseline and 12-week FIQ scores for the tai chi group were 62.9+/-15.5 and 35.1+/-18.8, respectively, versus 68.0+/-11 and 58.6+/-17.6, respectively, for the control group (change from baseline in the tai chi group vs. change from baseline in the control group, -18.4 points; P<0.001). The corresponding SF-36 physical-component scores were 28.5+/-8.4 and 37.0+/-10.5 for the tai chi group versus 28.0+/-7.8 and 29.4+/-7.4 for the control group (between-group difference, 7.1 points; P=0.001), and the mental-component scores were 42.6+/-12.2 and 50.3+/-10.2 for the tai chi group versus 37.8+/-10.5 and 39.4+/-11.9 for the control group (between-group difference, 6.1 points; P=0.03). Improvements were maintained at 24 weeks (between-group difference in the FIQ score, -18.3 points; P<0.001). No adverse events were observed.
Tai chi may be a useful treatment for fibromyalgia and merits long-term study in larger study populations. (Funded by the National Center for Complementary and Alternative Medicine and others; ClinicalTrials.gov number, NCT00515008.)
New England Journal of Medicine 08/2010; 363(8):743-54. DOI:10.1056/NEJMoa0912611 · 55.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Functional somatic syndromes include some of the most common and frustrating illnesses seen by primary care physicians and medical specialists. An extensive literature search of the 2 best characterized functional somatic syndromes, fibromyalgia and irritable bowel syndrome, reveals the overlap of these 2 disorders and their close relationship to depression. New pathophysiologic studies have shown that there are similar central nervous system changes in fibromyalgia, irritable bowel syndrome, and depression. These clinical and biologic similarities are consistent with the observations that the effective management of fibromyalgia and irritable bowel syndrome is comparable to that of depression.
The American journal of medicine 08/2010; 123(8):675-82. DOI:10.1016/j.amjmed.2010.01.014 · 5.00 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To develop simple, practical criteria for clinical diagnosis of fibromyalgia that are suitable for use in primary and specialty care and that do not require a tender point examination, and to provide a severity scale for characteristic fibromyalgia symptoms.
We performed a multicenter study of 829 previously diagnosed fibromyalgia patients and controls using physician physical and interview examinations, including a widespread pain index (WPI), a measure of the number of painful body regions. Random forest and recursive partitioning analyses were used to guide the development of a case definition of fibromyalgia, to develop criteria, and to construct a symptom severity (SS) scale.
Approximately 25% of fibromyalgia patients did not satisfy the American College of Rheumatology (ACR) 1990 classification criteria at the time of the study. The most important diagnostic variables were WPI and categorical scales for cognitive symptoms, unrefreshed sleep, fatigue, and number of somatic symptoms. The categorical scales were summed to create an SS scale. We combined the SS scale and the WPI to recommend a new case definition of fibromyalgia: (WPI > or =7 AND SS > or =5) OR (WPI 3-6 AND SS > or =9).
This simple clinical case definition of fibromyalgia correctly classifies 88.1% of cases classified by the ACR classification criteria, and does not require a physical or tender point examination. The SS scale enables assessment of fibromyalgia symptom severity in persons with current or previous fibromyalgia, and in those to whom the criteria have not been applied. It will be especially useful in the longitudinal evaluation of patients with marked symptom variability.
[Show abstract][Hide abstract] ABSTRACT: The roles of potential infectious agents in fibromyalgia and chronic fatigue syndrome are reviewed. There are significant overlaps in fibromyalgia and chronic fatigue syndrome. The clinical features and possibly the pathophysiologic mechanisms of these two disorders may be closely related.
[Show abstract][Hide abstract] ABSTRACT: A review of the literature suggests that fibromyalgia is not a psychiatric illness. A subset of patients have major depression and there is evidence that stress may play an important role in fibromyalgia. Depression may be a biologic marker for fibromyalgia in some families with a spectrum of "affective disorders."
[Show abstract][Hide abstract] ABSTRACT: Objective: To provide a concise overview of current treatment approaches in fibromyalgia. Findings: This review first discusses methodologic problems in prior fibromyalgia therapeutic trials. Then, controlled medication and non-medication studies are reviewed, with emphasis on the largest and most important reports. Finally, a discussion of multidisciplinary treatment of fibromyalgia is provided. Conclusions: No single therapeutic modality has been highly effective in patients with fibromyalgia. Judicious use of medication that decrease pain and promote better sleep, in conjunction with physical and psychosocial management, is currently the best approach to treatment.
[Show abstract][Hide abstract] ABSTRACT: This paper reviews the clinical trials of medications in the treatment of fibromyalgia. Methodologic issues in prior and future clinical trials are discussed. Although tricyclic medications and other central nervous system active medicines have been superior to placebo in clinical trials, no medications have been highly effective in the majority of patients with fibromyalgia.
[Show abstract][Hide abstract] ABSTRACT: Fibromyalgia is a chronic functional illness that presents with widespread musculoskeletal pain as well as a constellation of symptoms including fatigue, cognitive dysfunction, sleep difficulties, stiffness, anxiety, and depressed mood. The diagnosis of fibromyalgia, similar to other functional disorders, requires that organic diseases are not causing the symptoms. Systemic and rheumatic diseases can be ruled out by a patient history, physical examination, and laboratory investigations. Because there are no specific laboratory tests for fibromyalgia, the 1990 American College of Rheumatology (ACR) classification criteria have been used in clinical settings; however, they are not ideal for individual patient diagnosis. Clinicians should be aware of limitations inherent in using tender points in the diagnosis of fibromyalgia. The multiple symptoms of fibromyalgia often overlap with those of related disorders and may further complicate the diagnosis. One of the most challenging diagnostic dilemmas that clinicians face is distinguishing fibromyalgia from other central pain disorders (e.g., irritable bowel syndrome, chronic fatigue syndrome, migraine). Screening questions based on published criteria can be used as a first approach in diagnosing functional illnesses. Numerous studies report a higher prevalence of psychiatric disorders in patients with fibromyalgia. Therefore, a careful history and evaluation should be taken for the presence of primary mood disturbances. To date, there is no "gold standard" for diagnosing fibromyalgia. Until a better clinical case definition of fibromyalgia exists, all diagnostic criteria should be interpreted with caution, considered rudimentary, and subject to modification.
The American journal of medicine 12/2009; 122(12 Suppl):S14-21. DOI:10.1016/j.amjmed.2009.09.007 · 5.00 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Fibromyalgia (FM) is a soft tissue pain syndrome that has been estimated to affect 4% of the U.S. population. Precursor terms
such as “neurasthenia” and “fibrosi-tis” were used as early as the nineteenth century. The controversy about whether FM is
a disorder of the mind or of the body still rages. The American College of Rheumatology (ACR) criteria for the classification
of FM include a history of chronic, widespread body pain and at least 11 of 18 designated tender points on physical examination.
Patients with FM often have a variety of nonspecific complaints. As examples, fatigue, paresthesias, irritable bowel complaints,
subjective swelling of the hands and feet, sleep disturbances, migraine headaches, and deficits of attention and memory are
reported commonly in FM. Exercise is a critical part of therapy for FM.